Provider Demographics
NPI:1083651038
Name:KIM, TAE HYUN (D P M INC)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:HYUN
Last Name:KIM
Suffix:
Gender:M
Credentials:D P M INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13701 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-5040
Mailing Address - Country:US
Mailing Address - Phone:818-997-1216
Mailing Address - Fax:818-997-4458
Practice Address - Street 1:13701 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-5040
Practice Address - Country:US
Practice Address - Phone:818-997-1216
Practice Address - Fax:818-997-4458
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4262213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAO702ZMedicare PIN
CAU82730Medicare UPIN
CAE4262AMedicare ID - Type Unspecified